McGoon, Dwight C.

Calcific emboli were observed in 38 of 62 patients (61 per cent) who died at varying intervals following aortic valvotomy for calcific aortic stenosis. Major coronary embolization occurred in 10 patients (16 per cent) and was considered to be a major cause of death of four patients. Minor coronary embolization occurred in 33 patients (53 per cent) and was not directly implicated as a cause of death in any patient. Calcific emboli occurred to other organs in eight patients (13 per cent). The technics instituted for reducing the incidence of embolization—occlusion of coronary ostia, diligence in detection and removal of any debris, and final aspiration of the left ventricle—appeared to have had a favorable effect.

The problem of spontaneous calcific embolization was investigated at necropsy in 165 patients with calcific aortic stenosis. Minor coronary arteries contained calcific emboli in 18 patients (11 per cent), and major coronary arteries contained calcific emboli in 10 (6 per cent). Examination of the brain, kidney, and eye also disclosed spontaneous calcific emboli. In three instances of major coronary artery embolization, there was evidence of old silent infarction but no associated clinical disorder. Calcific embolization is apparently not rare in cases of calcific aortic stenosis, but this phenomenon does not appear to lead very often to extensive infarction or to clinically obvious disorders.

An anatomicopathologic entity of the tetralogy of Fallot with an additional finding of an accessory flap of tricuspid valvular tissue is described. In the 3 cases reported in this paper, the outstanding hemodynamic finding was a right ventricular systolic pressure that was significantly greater than the systemic systolic pressure. The hemodynamic findings were explained by the fact that the accessory tricuspid flap partially closed the large ventricular septal defect. The clinical picture was similar to that of either severe pulmonary stenosis with an intact ventricular septum or severe pulmonary stenosis with a small ventricular septal defect and a right-to-left shunt at the ventricular level.

Analysis of accumulated experience with the repair of atrial septal defect in 119 adults has revealed several factors determinable preoperatively that appear to have a strong influence on the operative risk. These factors are related to the presence of pulmonary vascular disease or heart failure and contribute importantly to the selection of patients for operation.

Pulmonic stenosis unassociated with a ventricular septal defect of significant size is often a complex abnormality. The stenosis may be valvular, infundibular, or both, and may be associated with an atrial septal defect or even with a small ventricular septal defect. Preoperative studies cannot accurately predict these variations. The surgical approach selected for such patients should permit the correction of each of the cardiac defects encountered. That this can be accomplished by means of extracorporeal circulation and open cardiotomy is demonstrated by the presented series of 10 cases without operative mortality.

The outlook for patients with double-outlet right ventricle has improved since the development of corrective operations. Late arrhythmic deaths after successful procedures have been reported; however, the magnitude remains unknown. This study was undertaken to identify the magnitude of late sudden death and the significant factors associated with it. From 1965 through 1985, 118 patients underwent corrective operation for double-outlet right ventricle; of these, 23 died in the hospital and six were lost to follow-up. The 89 remaining patients (52 male and 37 female) made up the study population. Their mean age (+/- SD) was 10.3 +/- 7.8 years at the time of repair. The mean duration of follow-up was 82 months. Of the 22 late deaths, 16 (73%) were sudden. Eight (50%) of the sudden deaths occurred within 1 year of operation. Cox proportional hazards multivariate analysis revealed the following significant risk factors for late sudden death: older age at the time of operation, perioperative or postoperative ventricular tachyarrhythmias, and third-degree atrioventricular block. Factors not associated with late sudden death included year of operation, sex, type and number of associated cardiac anomalies, preoperative functional class, previous palliative procedures, surgical technique, perioperative or postoperative single premature ventricular contractions, and postoperative left or right bundle branch block with or without fascicular block. We conclude that the incidence of late sudden death after successful surgical repair of double-outlet right ventricle is very high. Complete corrective operation at an early age and aggressive diagnosis and treatment of arrhythmias and conduction defects after operation are warranted.

In a group of 191 consecutive patients who underwent operation at the Mayo Clinic for isolated pulmonary valve stenosis between 1956 and 1967, late results were excellent. In patients surviving operation before the age of 21 years, long-term survival was similar to that in an age- and sex-matched control population. In the other patients, late survival and functional status were good, but survival was poorer than in the control population. This late attrition, most likely due to the sequelae of long-standing right ventricular hypertrophy, suggests the need for continued surveillance. Late sudden death occurred in only three patients, between 10 and 21 years postoperatively. The finding of normal life expectancy for such patients who survive operation before age 21 is important for actuarial purposes and for the patients' career and employment plans.